Gastrointestinal eosinophilic disorders (GIEDs) are a group of entities that include eosinophilic esophagitis, eosinophilic gastroenteritis, eosinophilic colitis, and eosinophilic enteritis, all of them characterized by mucosal infiltration of eosinophils and associated with digestive symptoms, after exclusion of other secondary causes.1 Recently, the prevalence of eosinophilic gastroenteritis and eosinophilic colitis in open US population was determined to be 5.1/100,000 and 2.1/100,000, respectively.2
Atopic comorbidities, such as asthma and allergic rhinitis, are found in up to 50% of cases. Peripheral eosinophilia occurs in 20%–80%.3 To establish the diagnosis of GIED, a high clinical suspicion, imaging, and endoscopic procedures that include mucosal biopsies are required.4 The histologic criteria for the diagnosis of GIED have been controversial for a long time because there is no evidence-based, widely accepted criteria.5 Regarding eosinophilic enteritis, Collins suggested the presence of >56 eosinophils per high power field (HPF) in a mucosal sample of ileum, eosinophilic cryptitis or crypt abscess, and altered eosinophil distribution.6 The treatment of GIED is based on diet modifications and oral corticosteroids.4
A 28-year-old woman, without medical history, allergies, or medication, was assessed for abdominal pain of 12 hours in the right lower quadrant. The patient denied any history of diarrhea, blood in the stool, fever, or recent travel. Laboratory results were normal, and abdominal computed tomography suggested a diagnosis of appendicitis; the histopathologic report was normal without any eosinophils. Due to persistent abdominal pain, further workup including stool ova and parasites, calprotectin, and magnetic resonance image enterography was performed, which did not report any abnormalities.
A video capsule endoscopy (VCE) showed a mucosal circumferential lesion in the ileum, associated with inflammation, ulceration, and partial stenosis (Figure 1). The capsule was retained in this site; therefore, a double balloon enteroscopy (DBE) was followed for the extraction of the capsule and for sampling of the mucosal lesion (Figure 2). However, capsule extraction was unsuccessful. Anatomopathologic examination of the biopsies showed mucosal infiltration of >52 eosinophils/HPF, eosinophilic cryptitis, increased epithelial mitotic activity, and altered eosinophil distribution with more than 4 eosinophils/HPF in the surface and crypt epithelium (Figure 3). Furthermore, a negative QuantiFERON-TB Gold test was obtained. Treatment with oral budesonide at a dose of 9 mg/d was initiated, observing prompt symptom improvement and spontaneous capsule elimination. After 6 months of treatment, a follow-up VCE was performed with previous use of patency capsule, to document mucosal response. It showed a significant improvement (90%) of the mucosal lesions (Figure 4). Currently, the patient remains asymptomatic with a steroid-reduced scheme.
Of the 3 conditions that compose GIED, eosinophilic enteritis is the most difficult to diagnose due to its location in the small bowel, thus representing a limitation for conventional endoscopic procedures. Furthermore, imaging tests have low sensitivity.7 Endoscopic features shown by VCE and DBE are mucosal edema, erythema, ulceration, and complete or partial stenosis, though not pathognomonic.8 There are only a few reports of eosinophilic enteritis diagnosed with VCE in the literature; however, the diagnostic confirmation is achieved through histologic examination of the mucosal biopsies by means of DBE or surgical resection. Due to possible stenosis of the mucosal lesions, this condition may represent a high risk of capsule retention. In case of retention, it is recommended to begin treatment with corticosteroids to allow spontaneous elimination of the capsule. If patients remain without symptoms of small bowel obstruction, one could avoid more invasive procedures such as surgical extraction.9 The overall VCE retention rate in the cases of eosinophilic enteritis is unknown.
The natural history of eosinophilic enteritis has been described with different disease course patterns such as single flare, recurring course, and a chronic persistent course without a period of remission. Currently, there is no well-established, evidenced-based treatment. However, corticosteroids have proven to be highly effective in multiple case series, as in our patient.10 The optimal duration of maintenance treatment is yet to be defined, based on the safety and efficacy.
Author contributions: G. Herrera-Quiñones drafted the manuscript. SI Scharrer, AR Jiménez-Rodríguez, OD Borjas-Almaguer, and JO Jáquez-Quintana performed the literature research. D. García-Compeán, JA Martínez-Segura, JA González-González, and HJ Maldonado-Garza revised the manuscript. D. García-Compean is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
1. Zhang M, Li Y. Eosinophilic gastroenteritis: A state-of-the-art review. J Gastroenterol Hepatol. 2017;32(1):64–72.
2. Mansoor E, Saleh MA, Cooper GS. Prevalence of eosinophilic gastroenteritis and colitis in a population-based study, from 2012 to 2017. Clin Gastroenterol Hepatol. 2017;15(11):1733–41.
3. Reed C, Woosley JT, Dellon ES. Clinical characteristics, treatment outcomes, and resource utilization in children and adults with eosinophilic gastroenteritis. Dig Liver Dis. 2015;47(3):197–201.
4. Rached AA, El Hajj W. Eosinophilic gastroenteritis: Approach to diagnosis and management. World J Gastrointest Pharmacol Ther. 2016;7(4):513.
5. Conner JR, Kirsch R. The pathology and causes of tissue eosinophilia in the gastrointestinal tract. Histopathology. 2017;71(2):177–99.
6. Collins MH. Histopathologic features of eosinophilic esophagitis and eosinophilic gastrointestinal diseases. Gastroenterol Clin North Am. 2014;43(2):257–68.
7. Abassa KK, Lin XY, Xuan JY, Zhou HX, Guo YW. Diagnosis of eosinophilic gastroenteritis is easily missed. World J Gastroenterol. 2017;23(19):3556–64.
8. Okuda K, Daimon Y, Iwase T, Mitsufuji S. Novel findings of capsule endoscopy and double-balloon enteroscopy in a case of eosinophilic gastroenteritis. Clin J Gastroenterol. 2013;6(1):16–9.
9. Rezapour M, Amadi C, Gerson LB. Retention associated with video capsule endoscopy: Systematic review and meta-analysis. Gastrointest Endosc. 2017;85(6):1157–68.e2.
© 2019 by Lippincott Williams & Wilkins, Inc.
10. De Chambrun GP, Gonzalez F, Canva JY, et al. Natural history of eosinophilic gastroenteritis. Clin Gastroenterol Hepatol. 2011;9(11):950–6.e1.